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					Quote Request and Census Form
Attention: Group Health Quotes
           Springs Health Plans
           2165 Hoodoo Dr.                                                    Email: group.health.quote@colvin.net
           Colorado Springs, Colorado 80919                                   Fax To: 719-884-1254
                 Highlighted information in bold letters is required. Missing information may delay the quote.

EMPLOYER:
 Company Name:                                                                        Effective Date:          # of Full Time Employees:


 Address                                                                              Contact Name:

 City:                                         State:           Zip Code:             Fax:                     Phone:

 SIC Code and/or Industry Type:                                                       Current Carrier:
 http://www.osha.gov/pls/imis/sicsearch.html


                   Employee Name or Initials    Employ   Employee’s           Elected          If coverage    Waived/COBRA
                                                 ee’s    Date of Birth      Coverage*           selected is    (if applicable)
                   Please do not enter          Gender     or Age           (see below)         EC or EF
                   employees’ dependents’        M/F                                             enter
                   names in this column.
                                                                                             # of Children
            1

            2

            3

            4

            5

            6

            7

            8

            9

            10

            11

            12

            13

            14

            15

            16

            17

            18

            19



** Elected Coverage:
  Employee Only = E Employee& Spouse only = ES Employee & Child(ren) only = EC Employee & Family = EF



           Please add additional pages as necessary. If you only use one page you are not subject to COBRA. If you add one or more
           pages, COBRA rules apply. When you apply for your group insurance a copy of your UITR (Unemployment Insurance Tax
           Return) will have to be submitted with your application.

				
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posted:10/13/2011
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